Healthcare Provider Details

I. General information

NPI: 1720934615
Provider Name (Legal Business Name): FORGE PSYCHIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2026
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 S 400 E STE 501
BOUNTIFUL UT
84010-4938
US

IV. Provider business mailing address

450 S 400 E STE 501
BOUNTIFUL UT
84010-4938
US

V. Phone/Fax

Practice location:
  • Phone: 385-399-8787
  • Fax: 385-359-0808
Mailing address:
  • Phone: 385-399-8787
  • Fax: 385-359-0808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JEREMY EASTON THUESON
Title or Position: MANAGER
Credential: MD
Phone: 385-399-8787